Cardiac autotransplant for surgical treatment of a malignant neoplasm.

Because of their anatomic location, cardiac sarcomas often interfere with cardiac function. Excision is considered to palliate the cardiac defect, but complete excision is often difficult owing to access, particularly in left atrial tumors. Incomplete resection results in tumor recurrence. To achieve complete resection of a large left atrial sarcoma, we used the technique of cardiac explantation, extracorporeal resection of the tumor with cardiac reconstruction, and cardiac autotransplantation.

High dose rate intracoronary radiation for inhibition of neointimal formation in the stented and balloon-injured porcine models of restenosis: angiographic, morphometric, and histopathologic analyses.

PURPOSE: We examined the effects of intracoronary irradiation delivered at a high dose rate on neointimal hyperplasia after injury induced by two methods: balloon overstretch injury, and stent implantation in a porcine model of coronary restenosis. METHODS AND MATERIALS: In 34 Hanford miniature swine, a segment of each coronary artery was targeted for injury and treatment. The artery segments were treated with 192Ir at doses of 10 Gy over 4 min (eight animals), 15 Gy over 6 min (nine animals), 25 Gy over 10 min (nine animals) or control (simulation wire only; eight animals). The treated segments were subjected to stent implantation (left anterior descending and right coronary artery) or balloon overstretch (circumflex) injury. Twenty-eight days later, repeat coronary angiography and sacrifice were done. Quantitative coronary angiography, morphometry, and extensive histopathologic analyses were carried out in a blinded fashion. RESULTS: The change in minimal lumen diameter from postinjury to presacrifice in the stent-injured left anterior descending was -0.79 +/- 0.34 (mean: +/- SD) mm in the control group, compared to -0.43 +/- 0.35 mm in the 15 Gy (p = 0.04) and -0.21 +/- 0.50 mm in the 25 Gy (p = 0.01) groups; and in the balloon-injured circumflex was -0.31 +/- 0.22 mm in the control group compared to -0.03 +/- 0.18 mm in the 10 Gy (p = 0.05) and 0.00 +/- 0.33 in the 15 Gy (p = 0.01) groups. Percent area stenosis in the left anterior descending was 36 +/- 9% in the control group compared to 18 +/- 12% in the 15 Gy (p = 0.003) and 11 +/- 11% in the 25 Gy (p < 0.001) groups; and in the circumflex was 16 +/- 10% in the control groups, compared to 5 +/- 5% in the 15 Gy (p = 0.02) and 2 +/- 2% in the 25 Gy (p = 0.009) groups. Histopathology showed a striking reduction in the amount of neointima in the irradiated arteries compared with control vessels. Other radiation effects were stromal fibrin exudate, thinning of the media, and adventitial fibrosis and leukocyte infiltration in the radiated arterial segments. CONCLUSIONS: High dose rate intracoronary irradiation with 192Ir effectively inhibits intimal proliferation after stent-induced as well as balloon-overstretch injury. This shorter treatment time (4 to 10 min) may provide a clinically practical approach to the prevention of restenosis after angioplasty.

Valvulitis involving a bioprosthetic valve in a patient with systemic lupus erythematosus.

A 37-year-old man with systemic lupus erythematosus, who underwent an aortic valve replacement with a Carpentier-Edwards porcine valve for severe aortic insufficiency, was admitted to the hospital with pulmonary edema. Transesophageal echocardiography revealed severe aortic insufficiency arising from partial dehiscence of the valve sewing ring, as well as centrally from the valve cusp. In addition, marked thickening of the mitral valve was observed with severe eccentric regurgitation. At surgery, valvulitis of the native mitral and bioprosthetic aortic valves was demonstrated, with a perforation of the porcine valve cusp. After replacement of both valves, the patient had a stormy postoperative course with recurrent communications between the left ventricle and atrium requiring multiple surgeries and eventually died. This case illustrates the severity of valvulopathy and ensuing complications that can affect patients with systemic lupus erythematosus and demonstrates that the valvulopathy can affect bioprosthetic valves, a finding that has significant implications as to the type of valve replacement in these patients.

Coronary artery spasm culminating in thrombosis following ergonovine stimulation.

A 53-yr-old active man with angina but no angiographically significant obstructive coronary artery disease developed refractory spasm following ergonovine provocation. This resulted in thrombus formation and myocardial infarction. As such, this is the first case in which thrombosis developed at the site of intense coronary artery spasm induced by ergonovine, all of which were documented angiographically. Despite the notable safety of this test, this case re-emphasizes the potential of ergonovine to produce intractable myocardial ischemia and infarction.

Papillary fibroelastoma. A right atrial presentation.

Papillary fibroelastoma is a rare cardiac tumor arising most frequently from valvular endocardium. These tumors are clinically important because of their tendency to embolize. Emphasis is therefore placed on early detection and surgical excision. We describe a case of a papillary fibroelastoma arising from the right atrium. To our knowledge, only 2 such cases have been reported in the English literature. Our case illustrates the discovery of a rare, but potentially fatal cardiac tumor, successfully removed by surgery.

Factors influencing the outcome of balloon aortic valvuloplasty in the elderly.

This study describes the short- and long-term outcome of 44 consecutive percutaneous balloon aortic valvuloplasty procedures performed in 42 elderly patients (age 77.8 +/- 7 years) with calcific aortic stenosis. The initial success rate was 95%, with the peak aortic valve pressure gradient declining from a mean of 82 +/- 32 mm Hg to 44 +/- 23 mm Hg and aortic valve area increasing from a mean of 0.59 +/- 0.15 cm2 to 0.83 +/- 0.40 cm2. One procedure-related death occurred and an additional three patients died less than or equal to 30 days after balloon aortic valvuloplasty. These patients all had New York Heart Association (NYHA) class IV heart failure symptoms prior to the procedure and their mean left ventricular ejection fraction (LVEF) (28 +/- 7%) was lower than that of hospital survivors (52 +/- 13%) (as was their ratio of left ventricular [LV] wall thickness-to-cavity ratio [0.50 +/- 0.10 versus 0.70 +/- 0.15]). At the time of hospital discharge after valvuloplasty, 76% of patients were asymptomatic or markedly improved (NYHA class I or II). After a mean follow-up of 15.5 months (range 2 to 26 months), however, 10 patients had died and 15 had undergone aortic valve replacement for recurrence of NYHA class III or IV symptoms. The adjusted 1- and 2-year survivals were 0.68 and 0.62, respectively, and adjusted 2-year event-free survival was 0.25. Proportional hazard regression analysis indicated that LVEF less than 40% was the only variable affecting survival (p less than 0.01) and was a possible indicator of event-free survival (p = 0.07).(ABSTRACT TRUNCATED AT 250 WORDS)